Provider Demographics
NPI:1184780728
Name:WALL, RICHARD J (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:WALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 50010
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-5010
Mailing Address - Country:US
Mailing Address - Phone:425-228-3440
Mailing Address - Fax:
Practice Address - Street 1:4011 TALBOT RD S
Practice Address - Street 2:STE 460
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5773
Practice Address - Country:US
Practice Address - Phone:425-251-5110
Practice Address - Fax:425-793-7382
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042456207RC0200X, 207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA104443Medicaid
WA0217509OtherL&I
WA4033WAOtherREGENCE
WAP00601617OtherMED RAILROAD
WA8472995Medicaid
WA4033WAOtherREGENCE
WA8472995Medicaid